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Food allergy in childhood has become a serious public health concern, significantly impairing quality of life and family functioning of affected infants and children. Approximately 8% to 9% of US children (5.6 million) younger than age 18 years have a food allergy, many of whom are at risk for anaphylaxis.1Given these concerning statistics, pediatric dentists will most certainly encounter children with food allergy in their dental practice. At the same time, in the the current climate of rapid change, new information is emerging and consensus guidelines have recently been developed on childhood food allergy. For these reasons, pediatric dentists must be knowledgeable about current guidance for the management and prevention of this potentially life-threatening chronic condition.
Hypotheses for Increased Prevalence of Childhood Food Allergy
The prevalence of childhood food allergy has been rising since 2010, and is possibly at a historic high.1While the increased prevalence of food allergy among children is multifactorial, there are three well-recognized theories that attempt to explain this concerning phenomenon2: the hygiene hyposthesis, the dual allergen exposure hypothesis, and the vitamin D hypotheis.
The hygiene hypothesis proposes that a lower incidence of infection in early childhood, resulting from decreased exposure to germs and infectious diseases, has contributed to an increase in allergic diseases. This hypothesis was first proposed in 1989 by Strachan, who asserted that, "over the past century, declining family size, improvements in household amenities, and higher standards of personal cleanliness have reduced the opportunity for cross-infection in young families…[resulting in] more widespread clinical expression of atopic disease." 3Observational studies have supported this hypothesis by showing that the mode of infant delivery, birth order, family size, non-farming environments, absence of pets in a household, antibiotics, and method of infant feeding may likely contribute to the development of food allergy.4 Siblings, pets, and a farming lifestyle have been reported to increase the microbial diversity of the environment and may decrease the risk of food allergy.5 Furthermore, studies suggest that an infant delivered via Cesarian section is not exposed to maternal bacteria from the birth canal, potentially increasing food allergy risk.6 The first 1,000 days of life from conception to age 2 years appear to be a critical time for food allergy prevention.4
The dual allergen exposure hypothesis posits that the route of exposure to potential food allergens (oral exposure versus cutaneous exposure) early in life contributes to the development of food allergy.7 When an infant is exposed to food protein through the gastrointestinal tract, food tolerance is established, but if an infant has eczema and is exposed to the food protein in the environment through dry, broken skin, the probability of food allergy is increased.7
Several studies support the vitamin D hypothesis, which proposes a potential role of UVB light exposure (ie, sunshine) and vitamin D insufficiency in the development of food allergy. Observational studies have revealed a greater prevalence of reported food allergies, emergency department visits for food-related allergic reactions, and prescriptions for epinephrine auto-injectors in geographical areas with lower sun exposure.8 Food allergy has also been found to be more common in children born in the fall and winter, suggesting that seasonal fluctuations in sunlight that contribute to insufficiency of vitamin D are involved in the pathogenesis of food allergy.9 Furthermore, a large-scale, population-based cohort study in Australia provided direct evidence that an adequate vitamin D level during infancy is an important protective factor against food allergy in the first year of life.10
The psychosocial impact of food allergy is a rapidly growing area of research. Mental health ramifications and potential long-term consequences of childhood food allergy include social isolation, poor nutritional status, depression, anxiety, post-traumatic stress, bullying victimization, and poor quality of life.11 Studies have found that children and adolescents who are victims of bullying have a high frequency of probable awake bruxism (PAB).12,13 Pediatric dentists can evaluate and treat food-allergic children for the dental sequelae of PAB, including headache, restoration fractures, tooth wear, temporomandibular disorders, and temporomandibular and facial pain.
Pathophysiology, Symptoms, and Allergic Reactions
Food allergy is an adverse immunologic response that is triggered by food protein antigens. As such, it is distinguished from food intolerance, which a non-immune reaction. The most common type of food allergy is an immunoglobulin E (IgE) reaction. IgE-mediated reactions occur when small amino acid sequences attach to IgE antibodies bound to mast cells, thereby triggering the release of potent mediators.
Symptoms of food allergy occur within minutes after ingesting the food and can quickly progress to anaphylaxis, a serious allergic response that may result in hypotension and shock. Oral signs and symptoms of anaphylaxis include hives around the mouth and swelling of the lips, tongue, and/or uvula, and patients may experience dyspnea and odynophagia.14 Anaphylaxis occurs as part of a clinical continuum and requires prompt identification and immediate epinephrine injection into the vastus lateralis muscle. Epinephrine is currently the first-line treatment for anaphylaxis, and early administration improves outcomes.14,15Foods that most often trigger anaphylaxis in children include egg, milk, wheat, and peanuts.16 Other common childhood food allergens include sesame, soy, tree nuts, fish, and shellfish. While epinephrine is necessary for anaphylaxis, a second-generation antihistamine is recommended for mild food allergic reactions.15
Nutritional and Oral Support
Limiting additive sugar intake not only reduces obesity and the risk of dental caries, but also improves periodontal health in adolescents.17 Allergen-free ("allergy-friendly") foods such as special allergen-free condiments and sauces, seed butters (as an alternative to peanut butter), gluten-free breads, cereals, and crackers, cookies, and granola bars, and plant-based yogurts often contain added sugars. The pediatric dentist plays a fundamental role in educating families to decrease intake of allergy-friendly foods that are high in added sugars.
Because a food-allergic child often must avoid an entire food group, he or she may not be meeting the recommended dietary intake for certain vital nutrients, and this adversely affects the child's growth and development.18 For instance, a child with a milk allergy must eliminate all dairy in the diet, including milk, cheese, butter, and yogurt, often resulting in a deficiency of calcium and other essential nutrients. A cross-sectional study observed that children with milk allergy or multiple food allergies consumed less dietary calcium compared with children without milk allergy and/or one food allergy.19 A recent study revealed that food-allergic school-age children in Cyprus were consuming inadequate amounts of calcium, niacin, fiber, and vitamin E.20
Poor nutrient intake affects the integrity of the tooth, surrounding tissues, and bone. A cross-sectional study in Brazil found that children with milk allergy had a higher rate and severity of caries.21 Intake of adequate calories, protein, vitamins, and minerals are necessary for normal salivary function, wound healing after oral surgery, and an overall healthy oral cavity. Thus, referral to a registered dietitian for nutritional counseling may be warranted for children with food allergy. Dietitians are invaluable in assisting children with food allergy, particularly in explaining to both the child and his or her caregivers the role of allergen avoidance, substituting the allergenic foods with allergen-free, healthy, nutrient-dense foods, and ensuring that a nutritionally balanced diet is maintained that will benefit the oral health of the child as well as his or her overall growth and development.
Safety in the Dental Office
To ensure patient safety during dental treatment for children with food allergies, it is increasingly important that the pediatric dentist take precautionary measures to check for potential allergens in medications as part of the patient's treatment. The dental office should have allergy-friendly policies, including restriction of all food and beverages to a designated area, such as the staff lounge. The medical history form should ask about food allergies and latex allergy, since cross-reactivity can occur between latex and foods. Latex allergy can be associated with allergy to avocado, kiwi, banana, sweet pepper, and tomato.22 In the taking the patient's history, the pediatric dentist should also inquire if the patient is carrying an epinephrine auto-injector, in the event of a reaction. Although uncommon, a food-allergic child may experience anaphylaxis in the dental office.
While immunotherapy protocols have shown promising data, additional research is needed for the development of a cure for food allergy. Currently, food allergy management is limited to strict allergen avoidance and prompt idenification and treatment of allergic reactions.23 Although avoidance of the allergenic food is all that is needed to prevent food allergic reactions, the ubiquitous presence of trace amounts of allergens in other foods, medications, and dental products makes complete avoidance very difficult, especially for children. It is important to note that even trace amounts of an allergen can cause a severe allergic reaction. While washing hands thoroughly with soap and water will remove allergens from the skin, hand gels and hand sanitizers do not remove food allergens.
The potential presence of allergens in in-office dental materials and products is an important concern for the pediatric dentist. Cow's milk allergy, a common food allergy among infants and young children, presents a significant clinical burden, as the food allergen most frequently occurring in the dental office is themilk protein, casein. The compound casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), which has been shown to have a synergistic effect on enamel remineralization when combined with fluoride,24 should never be used in the dental treatment of a child with a known milk allergy. The pediatric dentist should also be aware that allergens are often hidden in "natural flavorings." As part of the dental treatment plan, pediatric dentists should identify whether potential allergens are present in any prophylaxis paste, fluoride, polishing paste, dental cements, chewing gum, lip balms, or medications that are being considered for use in the patient. Most manufacturers of dental products will disclose which products are free of common allergens on their website and on the product label. If a medication contains lactose as an excipient, it is possible for milk proteins to contaminate the medication.25 The pediatric dentist can obtain information about the allergen content of a medication by checking with a pharmacist.
Food Allergy Prevention Guidance
Research has confirmed that during pregnancy, a nutrient-dense maternal diet that is low in additive sugar is associated with reduced risks of allergy and caries in offspring.26-28 The oral healthcare professional should help ensure prenatal care that reduces neonatal allergy risk by encouraging pregnant women and women of childbearing age to consume a healthy diet rich in nutrient-dense foods that contain little added sugar, such as vegetables, fruits, whole grains, seafood, eggs, beans, and unsalted nuts.29
Landmark studies, including the LEAP study30 and the PETIT study31 demonstrate that early introduction of allergens during complementary feeding (the introduction of solid and liquid foods other than breast milk or infant formula, in addition to breastfeeding or formula) may be an effective way to prevent food allergy. The LEAP study revealed that early introduction of peanuts into the infant's diet may prevent peanut allergy in high-risk infants.30 The PETIT study, a double-blind randomized placebo-controlled trial, found a significant reduction in egg allergy when young (aged 4 to 5 months) high-risk infants were introduced to heated egg powder.31 The results from these studies and others have led to a paradigm shift in infant feeding recommendations and new consensus guidance from leading allergy societies.32 Recommendations from the National Institutes of Allergy and Infectious Disease (NIAID)33 and the Dietary Guidelines for Americans published by the USDA29 suggest early introduction of allergenic foods into the infant's diet and including these foods in the child's diet regularly to prevent the development of food allergy. The NIAID guidelines advise families to include infant-safe forms of peanut during complementary food introduction, along with breastfeeding.33 The Dietary Guidelines for Americans acknowledge that the early introduction of infant-safe forms of peanut to complement breastfeeding may prevent peanut allergy.29As part of the interdisciplinary team, the pediatric dentist should encourage infant-safe food introduction, and in doing so they should also remind families that whole or crushed peanuts and crunchy peanut butter pose a significant choking hazard to infants and young children.
A healthy, diverse diet for infants and young children has benefit beyond food allergy prevention, including promoting a healthy dentition. Many options are currently available for early introduction of allergens, including early introduction foods (EIF) that are being marketed to help prevent food allergy. Pediatric dentists must consider the potential negative impact EIF may have on the young child's dental health. EIF in the form of crackers and "puffs" often contain refined and simple carbohydrates, and EIF baby food fruit pouches may contain added sugars, increasing the child's risk for obesity as well as caries.34
The goals of complementary feeding are to provide nutrition to meet growth and developmental needs, promote optimal oral health, and expose the infant to different flavors and food textures.29Oral healthcare professionals can encourage parents to offer their infant or young child foods that are easy to prepare, affordable, and nutrient-rich. Common potential allergens can be introduced in the form of hard-boiled eggs, plain yogurt, unsweetened peanut butter, tofu, seed butter, fish, wheat cereal, and tahini in infant-safe forms. Families can offer these complementary foods in age-appropriate forms, using a spoon or as finger foods to give the infant the opportunity to experience different food textures, flavors, and variety in their diet. These foods provide critical and immunomodulatory nutrients that infants and young children need for growth, development, and optimal oral health, and help promote food tolerance and prevent food allergies. Introduction of these complementary foods is a simple, efficient intervention that should be recommended during the child's first dental visit. Shared decision making is key, and the pediatric dentist plays an important role in ensuring optimal complementary feeding along with the pediatrician, registered dietitian, and allergist. Communication and collaboration with medical peers will optimize patient care.
Parents and other caregivers of a child with food allergy face several challenges in ensuring that their child will achieve important growth and development and optimal oral health, as well as in safeguarding against allergic food reactions. Pediatric dentists and other oral healthcare professionals can be a valuable resource to the child's parents, as well as to pregnant women, by providing them with education, support, and guidance as they navigate the process of early introduction of potential allergens in their child's diet to promote food tolerance and prevent food allergy. It is therefore important that the pediatric dentist is aware of the new infant feeding recommendations and consensus guidelines from leading allergy societies. Parents also require guidance and reassurance from the pediatric dentist and other healthcare professionals in order to overcome fear and misinformation concerning food allergies, which are common barriers to early dietary introduction of potential allergens. As an integral part of the healthcare team dedicated to caring for children with food allergy, the pediatric dentist can provide the information necessary for establishing healthy lifelong dietary and oral healthcare habits when it matters most, during the first 1,000 days of life, and continuing throughout childhood and beyond.
About the Authors
Ellen Karlin, MMSc, RDN, LDN, FADA
Private Practice, Scottsdale, Arizona
Sara Karlin, DDS
Board-certified Pediatric Dentist
Private Practice at The Kids' Dental Office
Arizona School of Dentistry and Oral Health
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